This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more.

Role Description

Under the direction of CDI Manager, the Clinical Documentation Specialist reviews medical records to facilitate accurate and complete medical record documentation to reflect clinical treatment, decisions, and diagnoses used for measuring and reporting hospital and physician outcomes.

• Accurately identifies additional documentation opportunities and places appropriate queries and/or communicates with physicians, coders, and other health team members for documentation improvement.
• Works independently and primarily in an approved remote home work environment.
• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.
• Accurately reviews medical records concurrently for completeness in documentation of diagnostic and procedural information for compliance to CMS, DOH regulatory, and financial requirements.
• Assures documentation of diagnoses, procedures, co-morbid, and complication conditions are reflected on the medical record.
• Prepares well written and compliant queries to communicate with physicians and other providers regarding missing, incomplete or clarifying information needed in the medical record.
• Works closely with coding staff to assure that documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care.
• Interacts and continuously educates physicians, nurse practitioners, and physician assistants.
• Provides real-time intervention/education when needed to promote correct coding, regulatory compliance, and correction of documentation deficiencies.
• Competent in utilizing all computer applications, e.g., Epic EHR, 3M DRG, MS Office.
• Maintains productivity expectations and accurately records activity in CDI software tracking tool.

Qualifications

• Bachelor of Science in Nursing
• Bachelor of Science in Health Information Management or related field
• Certification, Associate or Bachelor in other healthcare related field with experience noted below

Requirements

• CCDS, CDIP certification preferred
• RN/BSN preferred
• RHIA, or RHIT with CCS, MD or DO will be considered
• CCDS within 6 months of hire for eligible candidates
• Maintenance of appropriate registration/certification
• Responsible for tracking Continuing Education credits to maintain professional credentials if applicable

Experience Requirements

• Working knowledge of Medicare reimbursement system and coding structures preferred
• 5 years of Critical Care/Emergency medicine or 5 years of Medical Surgical Experience preferred
• 2-3 years Clinical Documentation Improvement experience or 5 years of Coding experience preferred
• MD/DO with two years of experience as a concurrent or retrospective coder or documentation specialist in an inpatient acute care facility using the United States IPPS system will be considered

Benefits

• Comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, and voluntary benefits.
• Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full-time service or two years of part-time service.
• All colleagues, including those who work less than part-time, have access to medical (including prescription) insurance.